Out-of-pocket expenditure on prenatal and natal care post Janani Suraksha Yojana: a case from Rajasthan, India
TL;DR: Results suggest that JSY has increased the coverage of institutional delivery and reduced financial stress to household and families but not sufficient for complicated delivery and Provisioning of providing sonography/other test and treating complicated cases in public health centres need to be strengthened.
Abstract: Though Janani Suraksha Yojana (JSY) under National Rural Health Mission (NRHM) is successful in increasing antenatal and natal care services, little is known on the cost coverage of out-of-pocket expenditure (OOPE) on maternal care services post-NRHM period. Using data from a community-based study of 424 recently delivered women in Rajasthan, this paper examined the variation in OOPE in accessing maternal health services and the extent to which JSY incentives covered the burden of cost incurred. Descriptive statistics and logistic regression analyses are used to understand the differential and determinants of OOPE. The mean OOPE for antenatal care was US$26 at public health centres and US$64 at private health centres. The OOPE (antenatal and natal) per delivery was US$32 if delivery was conducted at home, US$78 at public facility and US$154 at private facility. The OOPE varied by the type of delivery, delivery with complications and place of ANC. The OOPE in public health centre was US$44 and US$145 for normal and complicated delivery, respectively. The share of JSY was 44 % of the total cost per delivery, 77 % in case of normal delivery and 23 % for complicated delivery. Results from the log linear model suggest that economic status, educational level and pregnancy complications are significant predictors of OOPE. Our results suggest that JSY has increased the coverage of institutional delivery and reduced financial stress to household and families but not sufficient for complicated delivery. Provisioning of providing sonography/other test and treating complicated cases in public health centres need to be strengthened.
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TL;DR: NHM has been successful in increasing maternal care and reducing the catastrophic health spending in public health centers and Regulating private health centres and continuing cash incentive under NHM is recommended.
Abstract: The National Health Mission (NHM), one of the largest publicly funded maternal health programs worldwide was initiated in 2005 to reduce maternal, neo-natal and infant mortality and out-of-pocket expenditure (OOPE) on maternal care in India. Though evidence suggests improvement in maternal and child health, little is known on the change in OOPE and catastrophic health spending (CHS) since the launch of NHM. The aim of this paper is to provide a comprehensive estimate of OOPE and CHS on maternal care by public and private health providers in pre and post NHM periods. The unit data from the 60th and 71st rounds of National Sample Survey (NSS) is used in the analyses. Descriptive statistics is used to understand the differentials in OOPE and CHS. The CHS is estimated based on capacity to pay, derived from household consumption expenditure, the subsistence expenditure (based on state specific poverty line) and household OOPE on maternal care. Data of both rounds are pooled to understand the impact of NHM on OOPE and CHS. The log-linear regression model and the logit regression models adjusted for state fixed effect, clustering and socio-economic and demographic correlates are used in the analyses. Women availing themselves of ante natal, natal and post natal care (all three maternal care services) from public health centres have increased from 11% in 2004 to 31% by 2014 while that from private health centres had increased from 12% to 20% during the same period. The mean OOPE on all three maternal care services from public health centres was US$60 in pre-NHM and US$86 in post-NHM periods while that from private health center was US$170 and US$300 during the same period. Controlling for socioeconomic and demographic correlates, the OOPE on delivery care from public health center had not shown any significant increase in post NHM period. The OOPE on delivery care in private health center had increased by 5.6 times compared to that from public health centers in pre NHM period. Economic well-being of the households and educational attainment of women is positively and significantly associated with OOPE, linking OOPE and ability to pay. The extent of CHS on all three maternal care from public health centers had declined from 56% in pre NHM period to 29% in post NHM period while that from private health centres had declined from 56% to 47% during the same period. The odds of incurring CHS on institutional delivery in public health centers (OR .03, 95% CI 0.02, 06) and maternal care (OR 0.06, 95% CI 0.04, 0.07) suggest decline in CHS in the post NHM period. Women delivering in private health centres, residing in rural areas and poor households are more likely to face CHS on maternal care. NHM has been successful in increasing maternal care and reducing the catastrophic health spending in public health centers. Regulating private health centres and continuing cash incentive under NHM is recommended.
56 citations
TL;DR: In this paper, the authors explored views on costs and actual OOP payments during pregnancy and explored the source of funding for payments, and found that women needed to make payments despite the free maternal health policy.
Abstract: Introduction The free maternal health policy was implemented in Ghana in 2008 under the National Health Insurance Scheme (NHIS). The policy sought to eliminate out of pocket (OOP) payments and enhance the utilisation of maternal health services. It is unclear whether the policy had altered OOP payments for services. The study explored views on costs and actual OOP payments during pregnancy. The source of funding for payments was also explored. Methods A convergent parallel mixed methods design, involving quantitative and qualitative data collection approaches. The study was set in the Kassena-Nankana municipality, a rural area in Ghana. Women (n = 406) who utilised services during pregnancy were surveyed. Also, 10 focus groups discussions (FGDs) were held with women who used services during pregnancy as well as 28 in-depth interviews (IDIs) with midwives/nurses (n = 25) and insurance managers/directors (n = 3). The survey was analysed using descriptive statistics, focussing on costs from the women's perspective. Qualitative data were audio recorded, transcribed and translated verbatim into English where necessary. The transcripts were read and coded into themes and sub-themes. Results The NHIS did not cover all expenses in relation to maternal health services. The overall mean for OOP cost during pregnancy was GH¢17.50 (US$8.60). Both FGDs and IDIs showed that women especially paid for drugs and ultrasound scan services. Sixty-five percent of the women used savings, whilst twenty-two percent sold assets to meet the OOP cost. Some women were unable to afford payments due to poverty and had to forgo treatment. Participants called for payments to be eliminated and for the NHIS to absorb the cost of emergency referrals. All participants admitted the benefits of the policy. Conclusion Women needed to make payments despite the policy. Measures should be put in place to eliminate payments to enable all women to receive services and promote universal health coverage.
52 citations
TL;DR: Regression analyses revealed that among women having VB, interacting with care providers, being able to maintain privacy, and being free from fear of childbirth had a positive influence on overall satisfaction with the childbirth.
Abstract: Background: A woman’s satisfaction with childbirth services can have a significant impact on her mental health and ability to bond with her neonate. Knowing postnatal women’s opinions and satisfaction with services makes the services more women-friendly. Indian women’s satisfaction with childbirth services has been explored qualitatively, or by using non-standard local questionnaires, but scientific data gathered with standardised questionnaires are extremely limited.Objective: To measure postnatal Indian women’s satisfaction with childbirth services at selected public health facilities in Chhattisgarh, India.Methods: Cross-sectional survey using consecutive sampling (n = 1004) was conducted from March to May 2015. Hindi-translated and validated versions of the Scale for Measuring Maternal Satisfaction for Vaginal Births (VB) and Caesarean Births (CB) were used for data collection.Results: Although most of the women (VB 68.7%; CB 79.2%) were satisfied with the overall childbirth services received,...
48 citations
Cites background or result from "Out-of-pocket expenditure on prenat..."
...While other Indian studies describe a shortage of infrastructure, material and supply to support increased numbers of institutional childbirths [39,40,56], our review did not reveal other quantitative studies to prove or disprove our interpretations....
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...However, the expansion in the number of labour rooms and necessary resources and infrastructure, especially in public health facilities, has not been proportional to rising demand [36,39,40]....
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TL;DR: The proportion of institutional delivery increased with economic status and education and the proportion of deliveries in the private sector increased with wealth, maternal education, and age in Bangladesh and urban India.
Abstract: Maternity care in South Asia is available in both public and private sectors. Using data from demographic surveillance sites in Bangladesh, Nepal and rural and urban India, we aimed to compare institutional delivery rates and public-private share. We used records of maternity care collected in socio-economically disadvantaged communities between 2005 and 2011. Institutional delivery was summarized by four potential determinants: household asset index, maternal schooling, maternal age, and parity. We developed logistic regression models for private sector institutional delivery with these as independent covariates. The data described 52 750 deliveries. Institutional delivery proportion varied and there were differences in public-private split. In Bangladesh and urban India, the proportion of deliveries in the private sector increased with wealth, maternal education, and age. The opposite was observed in rural India and Nepal. The proportion of institutional delivery increased with economic status and education. The choice of sector is more complex and provision and perceived quality of public sector services is likely to play a role. Choices for safe maternity are influenced by accessibility, quantity and perceived quality of care. Along with data linkage between private and public sectors, increased regulation should be part of the development of the pluralistic healthcare systems that characterize south Asia.
30 citations
Cites background from "Out-of-pocket expenditure on prenat..."
...Importantly, poorer women were more likely than wealthier women to give birth in a public health facility in response to the scheme [77], although it did not compensate fully for the financial stress of complicated deliveries [78]....
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TL;DR: Caesarean births were significantly higher among mothers belonging to higher socioeconomic status, first order births, mothers with high BMI, pregnancy complications, repeat caesareans and in private health centres confirming that both maternal demand and institutional factors are leading to the increasing in caesAREan rates in India.
24 citations
References
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01 Jan 2008
TL;DR: Ban et al. as discussed by the authors stated that the global community cannot turn its back on the poor and the vulnerable, and that the goals are within reach, and even in the very poor countries, with strong political commitment and sufficient and sustained funding.
Abstract: “We cannot allow an unfavourable economic climate to prevent us from realizing the commitments made in 2000,” Mr. Ban states in the foreword to the Millennium Development Goals Report 2009. “The global community cannot turn its back on the poor and the vulnerable.” He adds: “Now is the time to accelerate progress towards the MDGs. The goals are within reach, and even in the very poor countries, with strong political commitment and sufficient and sustained funding.”
5,236 citations
01 Jan 2014
TL;DR: The estimates for 2013 presented in this report are the seventh in a series of analyses by the MMEIG to examine the global extent of maternal mortality and show trends from 1990 to 2013.
Abstract: A number of initiatives that commenced in recent years are geared towards achievement of the fifth millennium development goal (MDG 5: improving maternal health), most notably the launch of the global strategy for women's and children's health in 2010 by the United Nations (UN) Secretary-General. Measuring the MDG 5 target of reducing the maternal mortality ratio (MMR) by three quarters between 1990 and 2015 remains a challenge. Accordingly, the maternal mortality estimation inter-agency group (MMEIG), comprising the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), the United Nations Population Fund (UNFPA), the United Nations Population Division (UNPD), and the World Bank, together with a team at the National University of Singapore and University of California at Berkeley, United States of America, have been working together to generate internationally comparable MMR estimates. The estimates for 2013 presented in this report are the seventh in a series of analyses by the MMEIG to examine the global extent of maternal mortality. Consultations with countries were carried out following the development of the MMR estimates. The purposes of the consultations were: to give countries the opportunity to review the country estimates, data sources, and methods; to obtain additional primary data sources that may not have been previously reported or used in the analyses; and to build mutual understanding of the strengths and weaknesses of available data and ensure broad ownership of the results. This report presents global, regional, and country estimates of maternal mortality in 2013, as well as trends from 1990 to 2013. The report is organized as follows: chapter one gives introduction; chapter two provides an overview of the definitions and approaches for measuring maternal mortality. Chapter three is a detailed description of the methodology employed in generating the estimates. Chapter four presents the estimates and interpretation of the findings. Chapter five assesses the progress towards MDG 5. The annexes and appendices presents the sources of data for the country estimates, as well as MMR estimates for the different regional groupings for UNFPA, UNICEF, the UNPD, WHO, and the World Bank.
964 citations
TL;DR: More qualitative research is required to explore the effect of women's satisfaction, autonomy and gender role in the decision-making process as well as the main factors affecting the utilization of antenatal care in developing countries.
Abstract: Title. Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature.
Aim. This paper is a report of a systematic review to identify and analyse the main factors affecting the utilization of antenatal care in developing countries.
Background. Antenatal care is a key strategy for reducing maternal mortality, but millions of women in developing countries do not receive it.
Data sources. A range of electronic databases was searched for studies conducted in developing countries and published between 1990 and 2006. English-language publications were searched using relevant keywords, and reference lists were hand-searched.
Review methods. A systematic review was carried out and both quantitative and qualitative studies were included.
Results. Twenty-eight papers were included in the review. Studies most commonly identified the following factors affecting antenatal care uptake: maternal education, husband’s education, marital status, availability, cost, household income, women’s employment, media exposure and having a history of obstetric complications. Cultural beliefs and ideas about pregnancy also had an influence on antenatal care use. Parity had a statistically significant negative effect on adequate attendance. Whilst women of higher parity tend to use antenatal care less, there is interaction with women’s age and religion. Only one study examined the effect of the quality of antenatal services on utilization. None identified an association between the utilization of such services and satisfaction with them.
Conclusion. More qualitative research is required to explore the effect of women’s satisfaction, autonomy and gender role in the decision-making process. Adequate utilization of antenatal care cannot be achieved merely by establishing health centres; women’s overall (social, political and economic) status needs to be considered.
841 citations
TL;DR: This work identifies key challenges for the achievement of equity in service provision, and equity in financing and financial risk protection in India and suggests principles that will help to ensure a more equitable health care for India's population.
798 citations
TL;DR: JSY had a significant effect on increasing antenatal care and in-facility births and emphasise the need for improved targeting of the poorest women and attention to quality of obstetric care in health facilities.
720 citations
"Out-of-pocket expenditure on prenat..." refers background in this paper
...A number of evaluation studies reported the spectacular success of the various schemes in increasing access to maternal services [9, 11, 16, 17, 19]....
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...After one decade of the implementation of NRHM, especially Janani Suraksha Yojana (JSY), the largest conditional cash transfer programme in the world [9], a phenomenal increase was observed in institutional deliveries across Indian states [38]....
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